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Therapies/Treatments Advised
• • •
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Referrals Advised
• • •
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Activity Instructions
• • •
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Light Exercise/Activity Level Advised
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Opioids Prescribed
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Short Acting Opioids
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Short Acting Opioid SIG
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Long acting opioids
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Long Acting Opioid SIG
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Non Opioid SIG
• • •
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Non-opioid Meds Comments
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Trigger Point Injection With Ultrasound
• • •
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Trigger Point Injection Without Ultrasound
• • •
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Procedure Note: Lumbar Interlaminar Epidural
• • •
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Procedure Note: Cervical Interlaminar Epidural
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Lumbar Facet With Ultrasound
• • •
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Cervical Facet With Ultrasound
• • •
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Procedure Note: Left U/S Interscalene block
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Procedure Note: Right U/S Interscalene block
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SI joint injection w/ US
• • •
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Greater& Lesser Occipital Block
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Genicular Nerve Block
• • •
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Note: Right Subdeltoid Bursa Injection w/ U/S
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Ultrasound Guidance Necessity Statement
• • •
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Note: Left Subdeltoid Bursa Injection w/ U/S
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Physician Perform Manual Therapy
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Weight Loss Advised
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Prognosis Auto Injury
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Prognosis Work Comp Injury
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Prognosis Personal Injury
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Additonal Notes(free text)
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Will consider injection next visit?
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Violated Narcotic Agreement(Discharge)
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Discharge
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Diagnosis subject to change
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Face Time
• • •
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Follow Up?
• • •
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